Carvedilol yields survival gains in patients with cirrhosis, portal hypertension

Patients with cirrhosis and portal hypertension appear to achieve lower mortality with carvedilol than with variceal band ligation (VBL), a study has found.

The study included 152 patients (73 percent had alcohol-related liver disease) treated with either VBL (n=75) or carvedilol (n=77) to prevent first variceal bleed. In total, 146 patients (96 percent) contributed mortality data and 135 (89 percent) had available long-term follow-up data (up to 20 years).

More patients in the carvedilol vs VBL arm crossed over and received the alternative treatment (32 percent vs 16 percent) during their follow-up than vice versa (p=0.02). The most common reason for crossing over was the development of variceal bleeding (54 percent) among patients originally treated with carvedilol, and intolerance to the banding programme (64 percent) among patients who originally received VBL.

In the intention‐to‐treat analysis, carvedilol was associated with significantly better survival than VBL, with median of 7.8 years as opposed to 4.2 years (p=0.03). This survival advantage persisted in the per‐protocol analysis, when patients who switched between treatment arms were excluded (p=0.02).

Transplant‐free survival, liver‐related mortality, and decompensation events did not significantly differ between the treatment arms.

The present findings point to carvedilol as an advantageous pharmacological adjunct in patients with cirrhosis with portal hypertension. Potential mechanisms underlying such a benefit include a decrease in gastrointestinal congestion and thus gut permeability, and subsequently reduced bacterial translocation leading to a lower incidence of ascites and spontaneous bacterial peritonitis. These effects are said to be independent of the drug’s effect on portal pressure. [Ann Gastroenterol 2014;27:20-26; Gut 2015;64:1111-1119]